Equitable health services

World Malaria Report 2010
World Health Organisation: 2011

This report released by the World Health Organisation (WHO) reveals that a third of 306 anti-malarial medicines collected and tested from six African countries failed to meet international quality standards. Reasons for this failure include insufficient active pharmaceutical ingredient (API), an excess of degradation substances, and poor dissolution. In fact in two samples one of the APIs was totally absent. The countries surveyed were Cameroon, Ethiopia, Ghana, Kenya, Nigeria and Tanzania. The quality of anti-malarial medicines varied across countries, from Ethiopia – where no samples failed quality testing – to Nigeria, where the highest incidence of failure occurred (64%). This result implies that a patient in Nigeria is more likely to be treated with a substandard anti-malarial than a patient in a country that complies with international quality standards. Failure rates were noticeably low for WHO-prequalified medicines available in these countries (less than 4%) as well as for imported products manufactured by well-established manufacturers. The report concludes that WHO prequalification is a highly effective mechanism for verifying the quality of medicines.

Yellow fever vaccination coverage following massive emergency immunisation campaigns in rural Uganda, May 2011: a community cluster survey
Bagonza J, Rutebemberwa E, Mugaga M, Tumuhamye N and Makumbi I: BMC Public Health 13(202), 7 March 2013

This paper reports on yellow fever vaccination coverage following massive emergency immunisation campaigns in the Pader district, northern Uganda, in 2010. A total of 680 respondents were included in the sample and vaccination status was assessed in a survey using self reports and vaccination card evidence. Of the 680 respondents, 654 (96.3%) reported being vaccinated during the last campaign but only 353 (51.6%) had valid yellow fever vaccination cards. Of the 280 children below five years of age, 96.1% were vaccinated. The main reasons for not being vaccinated were: having travelled out of Pader district during the campaign period (40%), lack of transport to immunisation posts (28%) and sickness at the time of vaccination (16%). These results show that actual yellow fever vaccination coverage was high and met the desired minimum threshold coverage of 80% designated by the World Health Organisation. Active surveillance is necessary for early detection of yellow fever cases.

Yellow fever vaccine supply: a possible solution
Monath T; Woodall J; Gubler D; Yuill T; Mackenzie J;Martins R; Reiter P; Heymann D: The Lancet 387;10028; 1599–1600, 2016

The authors note the emerging epidemic of yellow fever in Angola and spread of similar Aedes aegypti mosquito-borne viruses including dengue, chikungunya, and now Zika, albeit with differences noted. Yellow fever was first identified as a viral infection in 1900, has been reported from more than 57 countries and yellow fever outbreaks have case fatality rates as high as 75% in hospitalised cases. There has been an effective yellow fever vaccine since the late 1930s, but with outbreaks in unvaccinated populations in 1987 in urban Nigeria, despite a mass vaccination campaign. According to WHO, the current yellow fever outbreak is in more than six of Angola's 18 provinces, and there has been movement of unvaccinated travellers from Angola to neighbouring Democratic Republic of the Congo, but also to further states, including Mauritania, and China. Southeast Asian countries are now considered at risk because the Aedes vector is present and the population is unvaccinated. However should yellow fever outbreaks occur elsewhere in Africa, in Latin America, or in Asia, the authors note that the current global supplies of yellow fever vaccine may be inadequate.

Zanzibar redoubles efforts to combat cholera
Integrated Regional Information Network, 24 January 2007

Cholera outbreaks in Tanzania's semi-autonomous island of Zanzibar have continued due to poor hygiene standards, health officials said on Wednesday, while announcing renewed efforts to raise public awareness. "We need to double our efforts of awareness; we also need to strengthen by-laws to make sure that the islands are kept clean," Dr Omar Suleiman, an officer in the Ministry of Health, said in Stone Town, capital of Zanzibar.

Zimbabwe Cholera and health situation - 1 December 2008
World Health Organisation

Zimbabwe’s overall health service has been steadily declining for the last five years. The Zimbabwean health service today is wracked by critical shortages of essential drugs and skilled and experienced personnel. Another challenge is there has been no comprehensive assessment of Zimbabwe’s health system since 2006, making it difficult to assess its true state. Also, its disease surveillance and early warning system, which depends on a weekly epidemiological system, has been compromised in terms of timeliness and completeness of data, which is only around 30%. Universal access to basic health services is compromised due to deteriorating infrastructure, staffing and financial resources. Reactivating primary health care services should keep being addressed as a matter of emergency. Zimbabwean health facilities face a massive gap – estimated this year at 70% – in required medicines due to reduced local manufacturing capacity, which has been weakened by a lack of foreign currency. This is despite support received from different partners through UNICEF’s procurement systems. A large cholera outbreak is affecting most regions of the country, with more than 11 700 cases and 473 deaths recorded between August and 30 November. This represents a case fatality rate (CFR) of 4.0% nationally, but reached 50% in some areas during the early stages of the outbreak. The CFR benchmark should be below 1%. Cholera outbreaks in Zimbabwe have occurred annually since 1998, but previous epidemics never reached today’s proportions. The last large outbreak was in 1992 with 3000 cases recorded. Cholera cases have also been reported either side of Zimbabwe’s border with South Africa, Botswana and Mozambique, demonstrating the subregional extent of the outbreak.

Zimbabwe fighting the spread of Polio - Again
Kwidini T: Inter Press Service, 25 June 2007

The Zimbabwe government and the United Nations Children’s Fund (UNICEF) conducted a countrywide immunisation programme aimed at eliminating polio and other diseases to prevent children from having the same experience as Chirewa and others. It is a continuation of similar efforts over the past few years. The programme has seen many mothers across the country taking their children to centres around the country for immunisation. About two million children were vaccinated during the week-long programme, not only immunised against polio but also against diseases such as tuberculosis, measles, diphtheria, tetanus, whooping cough and hepatitis B. They also received vitamin A supplements.

Zimbabwe's sick economy fuels growth of fake drug market
The Integrated Regional Information Networks (IRIN), 11 December 2006

Zimbabwe's deteriorating health services have made room for a thriving parallel market for drugs, many of them counterfeit, warn concerned health professionals. The sale of genuine as well as fake medicines on the streets was "big, booming business," said Dr Paul Chimedza, the president of the Zimbabwe Medical Association (ZIMA). "The health system has been adversely affected by the poorly performing economy. There is a general shortage of drugs within the country and unscrupulous dealers are capitalising on the situation by selling medical drugs on the streets."

‘I never had the money for blood testing’: Caretakers' experiences of care-seeking for fatal childhood fevers in rural Uganda: A mixed methods study
Hildenwall H, Tomson G, Kaija J, Pariyo G and Peterson S: Health and Human Rights 8(12), 2 December 2008

This study explores caretakers' experiences of care-seeking for childhood febrile illness with fatal outcome in rural Uganda to elucidate the most influential barriers to adequate care. A mixed methods approach using structured Verbal/Social autopsy interviews and case narratives was employed with 26 caretakers living in the Iganga/Mayuge Demographic Surveillance Site who had lost a child 1–59 months old due to acute febrile illness between March and June 2006. The main barriers to care were misdiagnosis by the caregiver, gender and household financial constraints, and dissatisfaction with providers, reflecting inadequate levels of service. Poverty was identified as the underlying theme. Any improvements in basic health care for children suffering from acute febrile illness are likely to substantially reduce mortality.

‘You must carry your wheelchair’ – barriers to accessing healthcare in a South African rural area
Vergunst R; Swartz L; Mji G; MacLachlan M; Mannan H: Global Health Action 8(1); http://dx.doi.org/10.3402/gha.v8.29003, 2017

There is international evidence that people with disabilities face barriers when accessing primary healthcare services and that there is inadequate information about effective interventions that work to improve the lives of people with disabilities, especially in low-income and middle-income countries. Poor rural residents generally experience barriers to accessing primary healthcare, and these problems are further exacerbated for people with disabilities. This study explored the challenges faced by people with disabilities in accessing healthcare in Madwaleni, a poor rural Xhosa community in South Africa. Purposive sampling was done with 26 participants, using semi-structured interviews and content analysis to identify major themes. The study showed a number of barriers to healthcare for people with disabilities. These included practical barriers, including geographical and staffing issues, and attitudinal barriers.

“I cry every day and night, I have my son tied in chains”: physical restraint of people with schizophrenia in community settings in Ethiopia
Asher L; Fekadu A; Teferra S; De Silva M; Pathare S; Hanlon C: Globalisation and Health 13(47), doi: 10.1186/s12992-017-0273-1, 2017

A primary rationale for scaling up mental health services in low and middle-income countries is to address human rights violations, including physical restraint in community settings. The voices of those with intimate experiences of restraint, in particular people with mensystetal illness and their families, are rarely heard. This study aimed to understand the experiences of, and reasons for, restraint of people with schizophrenia in community settings in rural Ethiopia in order to develop constructive and scalable interventions. A qualitative study was conducted, involving 15 in-depth interviews and 5 focus group discussions with a purposive sample of people with schizophrenia, their caregivers, community leaders and primary and community health workers in rural Ethiopia. Most of the participants with schizophrenia and their caregivers had personal experience of the practice of restraint. The main explanations given for restraint were to protect the individual or the community, and to facilitate transportation to health facilities. These reasons were underpinned by a lack of care options, and the consequent heavy family burden and a sense of powerlessness amongst caregivers. Whilst there was pervasive stigma towards people with schizophrenia, lack of awareness about mental illness was not a primary reason for restraint. All types of participants cited increasing access to treatment as the most effective way to reduce the incidence of restraint. Restraint in community settings in rural Ethiopia entails the violation of various human rights, but the underlying human rights issue is one of lack of access to treatment, calling for the scale up of accessible and affordable mental health care.